2004 Panel of the Survey of Income and Program Participation Waves 10, 11, & 12

OMB No. 0607-0905: Approval Expires 02/28/2007
U.S. DEPARTMENT OF COMMERCE

SIPP-24003

FORM
(8-26-2003)

Economics and Statistics Administration

REMINDER CARD

U.S. CENSUS BUREAU

SURVEY OF INCOME AND PROGRAM PARTICIPATION
The Census field representative will call back
for the information marked (X) below for

Name of household member

–
–
1. Social Security or Railroad Retirement number
(for Wave 2+ interviews only)
Please list the Social Security or Railroad Retirement numbers for the following
household members:
Name

Social Security or Railroad Retirement number
–

–

–

–

–

–

–

–

2. EMPLOYER(S)
What was your GROSS INCOME for each of the times you were paid for the month(s) indicated?
a. Employer No. 1

b. Employer No. 2

Month

Month

Month

Month

$

$

$

$

Month

Month

Month

Month

$

$

$

$

3. SELF-EMPLOYED/BUSINESS
What was the TOTAL INCOME earned from this self-employment for the month(s) indicated?
a. Self-employment No. 1

b. Self-employment No. 2

Month

Month

Month

Month

$

$

$

$

Month

Month

Month

Month

$

$

$

$

Notes

USCENSUSBUREAU

CONTINUE ON REVERSE SIDE

Amounts for the period –
Item description
through
Held jointly with your
spouse

$

Owned individually

$

Held jointly with your
spouse

$

Owned individually

$

Held jointly with your
spouse

$

Owned individually

$

7. What was the total amount of INTEREST
earned on any CERTIFICATES OF
DEPOSIT (CD’s) for the period shown
above?

Held jointly with your
spouse

$

Owned individually

$

8. What was the total amount of INTEREST
earned on any MUNICIPAL or
CORPORATE BONDS for the period
shown above?

Held jointly with your
spouse

$

Owned individually

$

9. What was the total amount of INTEREST
earned on any U.S. GOVERNMENT
SECURITIES for the period shown above?

Held jointly with your
spouse

$

Owned individually

$

Made out jointly to
you and your spouse

$

In your own name

$

11. How much was earned as DIVIDENDS
CREDITED AGAINST A MARGIN
ACCOUNT or AUTOMATICALLY
REINVESTED from any MUTUAL FUNDS
for the period shown above?

Held jointly with your
spouse

$

Owned individually

$

12. What was the total amount of DIVIDEND
CHECKS earned from any STOCKS for the
report period indicated above?

Made out jointly to
you and your spouse

$

In your own name

$

Held jointly with your
spouse

$

Owned individually

$

4. What was the total amount of INTEREST
earned on any interest earning CHECKING
ACCOUNT for the period shown above?

5. What was the total amount of INTEREST
earned on any SAVINGS ACCOUNT for the
period shown above?

6. What was the total amount of INTEREST
earned on any MONEY MARKET DEPOSIT
ACCOUNT for the period shown above?

10. What was the total amount of DIVIDEND
CHECKS earned from any MUTUAL
FUNDS for the period shown above?

13. How much was earned as DIVIDENDS
CREDITED AGAINST A MARGIN ACCOUNT
or AUTOMATICALLY REINVESTED from any
STOCKS for the period indicated above?
14. Are you covered by health insurance in the
current month?
15. Were you covered by
health insurance in the
following month(s)?
FORM SIPP-24003 (8-26-2003)

Month

Month

Yes
No
Month

Yes
No

Month

Yes
No

Month

Yes
No

Yes
No